Executive Function

Evidence Reviewed as of before: 19-08-2017
Author(s): Tatiana Ogourtsova, PhD Cand. MSc OT; Nicol Korner-Bitensky, PhD OT; Annabel McDermott, OT; Deirdre Dawson, PhD OT
Expert Reviewer: Valérie Poulin, OT,  PhD
Patient/Family Information Table of contents

Introduction

Executive functions (EF) refer to high-level cognitive functions that are responsible for the initiation, planning, sequencing, and monitoring of complex goal-directed behaviour. Disorders in EF after stroke are very common and can affect performance of activities of daily living and self-care, participation in social activities, and independence in more complex activities (e.g. returning to work, driving, caring for others). Executive functions include skills such as inhibition/impulse control, flexible thinking, emotional control, task initiation, memory and attention, planning, organisation of self and materials, and self-monitoring.

There are a variety of treatment approaches for EF deficits. Some interventions reviewed in this module focus on remediation of specific EF abilities affected by stroke (e.g. memory retraining using computer-based tasks, virtual reality programs). Other interventions use compensation approaches, for instance through cognitive strategies (e.g. Cognitive Orientation to daily Occupational Performance training, problem-solving training) or external mechanisms (e.g. electronic paging systems).

Patient/Family Information

What is Executive Function (EF)?

Executive functions (EF) are complex mental skills and abilities that help us to manage our attention and behaviour so we can achieve our goals.

EF involve abilities such as:

  • starting tasks
  • planning tasks
  • paying attention
  • holding information in our mind while using it for a short period of time (e.g. remembering numbers as we dial a phone number)
  • stopping inappropriate actions
  • multitasking
  • solving problems
  • monitoring our own progress and adjusting our approach in new or unexpected situations

We use EF every day during common activities such as dressing or preparing a meal, as well as more difficult activities related to work and leisure.

EF can be affected by a stroke. A person who has had a stroke may have difficulties with simple self-care activities (e.g. grooming, dressing) and/or more complex activities (e.g. cooking, grocery shopping, driving, childcare, return to work) that require EF.

How frequent are EF problems after a stroke?

EF problems are very common, and happen in 19% to 75% of people after a stroke.

What are the potential consequences of EF problems?

When a person has EF problems after stroke it can affect their ability to do familiar activities such as caring for themselves, managing their home, working and driving a car. It can also affect a person’s ability to respond to new or unexpected situations.

For example, a person with EF problems might have difficulty preparing a meal because they forget to gather the correct ingredients or they mix up the order of steps when putting the foods together. They might forget to turn a hotplate on before cooking, or to turn the hotplate off after cooking. They might burn the meal because they got distracted during cooking.

As another simple example, a person with EF problems after stroke might have difficulty meeting up with a friend because they cannot figure out what time they need to leave their own house to get to the meeting place on time, or get distracted by another activity on his/her way to the meeting place.

There are strategies and approaches that can be used to help people with EF problems after stroke.

Can EF problems caused by a stroke be treated?

There are three different treatment approaches for EF problems after a stroke. They aim to:

  1. Restore the EF abilities affected by a stroke
  2. Teach strategies to compensate for EF abilities affected by the stroke
  3. Use external aids or environmental modifications

These approaches are described below.

1. Restoring EF abilities that have been affected by a stroke

This approach involves practicing the skills you have difficulty with until you see improvement. Interventions may involve computer-based training or face-to-face training with a therapist.

Computer-based training can be used to train skills such as:

  • working memory: the ability to hold information in our mind and work with it for a short period of time (e.g. dialing a phone number or doing mental calculations)
  • dual task: the ability to coordinate two tasks at once (e.g. turning the steering wheel and pressing the gas pedal at the same time while driving).

Computer activities to work on these skills use numbers, letters, words, and shapes, and also simulate daily life tasks.

NOTE: Don’t be concerned if you are not familiar with computers – these programs work quite simply and your therapist will show you how to use them easily.

Face-to-face training with the therapist can be used to train skills such as:

  • verbal working memory: the ability to hold verbal information in our mind and work with it for a short period of time (e.g. reading long sentences). Training for verbal working memory uses different activities such as word spelling or sorting a series of words into alphabetic order.

2. Teaching strategies to compensate for EF abilities affected by the stroke

This approach may involve learning and applying strategies to solve everyday problems and to handle everyday situations in a more structured way.

Specific treatments that are being tried in recent years to help people with EF problems after a stroke include:

Problem-solving training, where the person learns to make use of a common every day task they are comfortable with to help them learn other similar tasks – by comparing one to the other and identifying similarities in “how to” perform the task.

Goal Management Training, where the person learns to take time to stop while doing an activity in order to reflect on the goal of their task and to self-monitor their performance. This training often includes some written materials, interactive tasks, a discussion with your clinicians of real-life concerns you are experiencing when doing specific tasks since your stroke etc.

Cognitive Orientation to daily Occupational Performance (CO-OP) approach, where your clinician helps you identify strategies that will make it easier for you to achieve goals that have become more difficult since your stroke. For example, you may find it harder to remember to organize your week and get to your scheduled appointments. Your clinician would help you to come up with strategies that work for you to make these activities easier to do.

3. Teaching the use of external aids / environmental modifications

This may involve using paging systems, step-by-step checklists or environmental modifications in order to complete daily activities:

Electronic paging systems consist of reminders sent to standard pagers to assist with memory & planning. You would receive electronic prompts to carry out tasks you want to accomplish such as taking medication or remembering appointments.

Paper and pencil checklists: With the clinician’s help, you would make a list of each step or task that needs to be done. You would tick off each task/step once it has been done and record the total time taken to complete the task.

Environmental modifications consist of changes to everyday objects or settings (e.g. use of a dosette box for medication, labelling things around the home or workplace, etc.).

Which EF treatments work?

There is limited but encouraging evidence to suggest that people with stroke can benefit from retraining specific EF abilities (e.g. computer-based training of working memory) and using compensatory strategies (e.g. problem-solving strategies, goal management training, paging systems). These strategies may improve different aspects of EF and, possibly, a person’s ability to accomplish daily activities.

Who provides the treatment?

Occupational therapists (OT), neuropsychologists and speech language pathologists can provide this therapy at an acute care hospital, rehabilitation centre, or private clinic.

Are there any side effects/risks to EF treatments?

There are no specific risks and/or side effects involved in EF treatment post-stroke. You are encouraged to take breaks as needed and respect your level of fatigue when participating in EF training. Your treating health care professional will adjust the training according to your needs and abilities.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

A systematic literature review on the effectiveness of EF interventions post-stroke was conducted in January 2011 (please see the paper from Poulin, V., Korner-Bitensky, N., Dawson, D., & Bherer, L. (2012). Efficacy of executive function interventions after stroke: a systematic review.Topics in Stroke Rehabilitation, 19(2), 158-171) and was updated in February 2013 and August 2017 for the purpose of this module.

Currently, 15 RCTs that meet the inclusion criteria are included in the module. Six of them are high quality studies, eight are fair quality RCTs and one is a low quality RCT.

In patients with acute stroke, EF intervention included computer interventions. Computer interventions were found to be more effective than comparison treatments in improving outcomes such as overall cognitive functions, selective attention, processing speed and complex attention, and working memory; but not outcomes related to frontal lobe function, functional independence, reasoning, verbal fluency/language and visuo-constructive abilities.

In patients with chronic stroke, EF interventions included computer interventions, paging system, strategy training and virtual reality. Computer interventions were found to be more effective than comparison treatments in improving attention, self-perceived health and memory; but not cognitive function, reasoning, occupational performance, processing speed and complex attention, and quality of life. Paging system was found to be more effective than comparison treatments in improving task completion. Strategy training was found to be more effective than comparison interventions in improving concept formation and cognitive flexibility; but not instrumental activities of daily living. Virtual reality was found to be more effective than comparison interventions in improving attention, cognitive function, verbal fluency/language; but not memory, processing speed and complex attention, reasoning, stroke outcomes, and visuospatial skills.

In patients with stage of stroke recovery not specific to one period, EF interventions included the CO-OP approach, computer interventions, strategy training, time pressure management, and virtual reality. The CO-OP approach was found to be more effective than comparison interventions in improving stroke outcomes; but not outcomes related to dysexecutive deficits, cognitive flexibility, life habits, occupational performance, processing speed and complex attention and working memory. Computer interventions were found to be more effective than comparison interventions in improving unilateral spatial neglect, frontal lobe function, processing speed and complex attention; but not mood, cognitive function, dysexecutive deficits, cognitive flexibility, life habits, occupational performance, and working memory. Strategy training was found to be more effective than comparison interventions in improving mood, cognitive flexibility and functional independence; but not inhibition. Time pressure management was found to be more effective than comparison interventions in improving information intake and speed of information processing; but not cognitive function, inhibition, attention, fatigue, functional independence, mood, processing speed and complex attention, quality of life and working memory. Virtual reality was found to be more effective than a comparison intervention in improving attention and working memory.

Outcomes

Acute phase - Computer interventions

Cognitive function
Effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on cognitive function in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Cognitive function was measured by the Mini-Mental State Examination (MMSE) at post-treatment (4 weeks). Significant between-group differences were found, favoring computer executive function training vs. sham intervention.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is more effective than a comparison intervention (sham intervention) in improving cognitive function in patients with acute stroke.

Frontal lobe function
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on frontal lobe function in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Frontal lobe function was measured by the Frontal Assessment Battery at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving frontal lobe function in patients with acute stroke.

Functional independence
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Functional independence was measured by the Functional Independence Measure at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving functional independence in patients with acute stroke.

Processing speed and complex attention
Effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on processing speed and complex attention in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Processing speed and complex attention were measured by the Trail Making Test A&B at post-treatment (4 weeks). Significant between-group differences were found, favoring computer executive function training vs. sham intervention.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is more effective than a comparison intervention (sham intervention) in improving processing speed and complex attention in patients with acute stroke.

Reasoning
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on reasoning in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or a sham intervention. Non-verbal reasoning was measured by the Progressive Matrices 47 at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving non-verbal reasoning in patients with acute stroke.

Selective attention
Effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on visual selective attention in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Visual selective attention was measured by the Attentive Matrices at post-treatment (4 weeks). Significant between-group differences were found, favoring computer executive function training vs. sham intervention.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is more effective than a comparison intervention (sham intervention) in improving visual selective attention in patients with acute stroke.

Verbal fluency / language
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on verbal fluency in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Verbal fluency was measured by the Phonological Fluency and Semantic Fluency Tests at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving verbal fluency in patients with acute stroke.

Visual-constructive abilities
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on visual-constructive abilities in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Visual-constructive abilities were measured by the Rey-Osterrieth Figure Copy Test at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving visual-constructive abilities in patients with acute stroke.

Working memory
Effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effects of a computer-based intervention on memory in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Measures of memory were taken at post-treatment (4 weeks) and included: (i) episodic memory, measured by the Rey Auditory Verbal Learning Test (RAVLT – immediate and delayed recall); (ii) verbal working memory, measured by the Digit Span Test; (iii) spatial memory, measured by Corsi’s Test; and (iv) logical memory, measured by the Logical Memory Test (immediate and delayed recall). At post-treatment there were significant between-group differences in episodic memory (RAVLT – delayed recall only) and logical memory (immediate and delayed), favoring computer executive function training vs. sham intervention. There were no significant differences in verbal memory or spatial memory.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is more effective than a comparison intervention (sham intervention) in improving episodic and logical memory (but not verbal or spatial memory) in patients with acute stroke.

Chronic phase - Computer interventions

Attention
Effective
2a

Two fair quality RCTs (Westerberg et al., 2007; Lundqvist et al., 2010) investigated the effect of a computer intervention on attention in patients with chronic stroke.

The first fair quality RCT (Westerberg et al., 2007) randomized patients to receive home-based computer-assisted working memory training or no treatment. Attention was measured by the Stroop Interference Test and the Ruff 2&7 Test (selective attention), and the Paced Auditory Serial Attention Test (PASAT- Version A, sustained/divided attention) at post-treatment (5 weeks). There were significant between-group differences in one measure of selective attention (Ruff 2&7) and in measures of sustained/divided attention (PASAT – Version A) at post-treatment, in favour of computer-assisted working memory training vs. no training.

The second fair quality cross-over RCT (Lundqvist et al., 2010) randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Attention was measured by the PASAT, Listening Span Task and Picture Span Task at 4 weeks post-treatment (short-term follow-up) and at 20 weeks post-treatment (long-term follow-up). Between-group differences for attention were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline at both follow-up time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-assisted working memory training is more effective than no treatment in improving attention in patients with chronic stroke. A second fair quality RCT also reported improvements following computer-assisted working memory training.

Cognitive flexibility
Insufficient evidence
5

One fair quality RCT (Lundqvist et al., 2010) investigated the effect of a computer intervention on cognitive flexibility in patients with chronic stroke. This fair quality cross-over RCT randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Cognitive flexibility was measured by the Delis-Kaplan Executive Function System – Colour Word Interference Test Condition 4 – Inhibition/Switching at 4 weeks post-treatment (short-term follow-up) and 20 weeks post-treatment (at long-term follow-up). Between-group differences in cognitive flexibility were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline at both follow-up time points.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of computer-assisted working memory training on cognitive flexibility in patients with chronic stroke. However, a fair quality RCT found significant improvement in cognitive flexibility following computer-assisted working memory training.

Memory
Effective
2a

Three fair quality RCTs (Westerberg et al., 2007; Lundqvist et al., 2010; Lin et al., 2014) investigated the effect of computer interventions on memory in patients with chronic stroke.

The first fair quality RCT (Westerberg et al., 2007) randomized patients to receive home-based computer-assisted working memory training or no treatment. Memory outcomes included: (i) auditory working memory, measured by the Wechsler Adult Intelligence Scale – Revised NI (WAIS-R NI – Digit Span Test); (ii) delayed recall, measured by the Claeson-Dahl Word List Test – Delayed Recall; and (iii) visual-spatial working memory, measured by the WAIS-R NI – Span Board Test. Significant between-group differences in auditory working memory and visual-spatial working memory (WAIS-R NI – Digit Span Test, Span Board Test) were found at post-treatment, favoring computer-assisted working memory training vs. no treatment.

The second fair quality cross-over RCT (Lundqvist et al., 2010) randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Working memory was measured by the WAIS-R NI – Block-Span-Board (forwards, backwards) at 4 weeks post-treatment (short-term follow-up) and at 20 weeks post-treatment (long-term follow-up). Between-group differences for memory were not reported. Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline to both follow-up time points.

The third fair quality RCT (Lin et al., 2014) randomized patients to receive computer-assisted memory/executive function training or no therapy. Working memory was measured by the Wechsler Memory Scale (WMS – information, orientation, mental control, logical memory, digits forward and backward, visual reproduction, associated learning, memory quotient) at post-treatment (10 weeks). Between-group differences in memory functions were not reported. There were significant within-group differences in memory functions (WMS – mental control, logical memory, digits forward and backward, visual reproduction, associated learning, memory quotient) from baseline to post-treatment in the computer-assisted memory/executive function training group, whereas significant gains were not seen in the group that received no training.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that home-based computer –assisted working memory training is more effective than no treatment in improving memory in patients with chronic stroke. Two other RCTs reported improvements following computer-assisted working memory training program.

Occupational performance
Insufficient evidence
5

One fair quality RCT (Lundqvist et al., 2010) investigated the effect of a computer intervention on occupational performance in patients with chronic stroke. This fair quality cross-over RCT randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – performance and satisfaction scales) at 20 weeks after training. Between-group differences for occupational performance were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline to follow-up.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of computer-assisted working memory training on occupational performance in patients with chronic stroke. However, a fair quality RCT found significant improvement in occupational performance following computer-assisted working memory training.

Processing speed and complex attention
Insufficient evidence
5

One fair quality RCT (Lin et al., 2014) investigated the effect of computer intervention on processing speed and complex attention in patients with chronic stroke. This fair quality RCT randomized patients to receive computer-assisted memory/executive function training or no computer training. Processing speed and complex attention were measured by the Trail Making Test A & B at baseline and post-treatment (10 weeks). Between-group differences in processing speed and complex attention were not reported; the group that received computer training demonstrated significant improvement on one measure of processing speed and complex attention (Trail Making Test A) from baseline to post-treatment.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of computer-assisted memory and executive function training on processing speed and complex attention. However, a fair quality RCT found significant improvement in processing speed and complex attention following computer-assisted memory/executive function training.

Quality of life
Insufficient evidence
5

One fair quality RCT (Lundqvist et al., 2010) investigated the effect of a computer intervention on quality of life in patients with chronic stroke. This fair quality cross-over RCT randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Quality of life was measured by the EQ-5D at 20 weeks after training. Between-group differences for quality of life were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed no significant improvement from baseline to follow-up.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of computer-assisted working memory training on quality of life in patients with chronic stroke. Also, a fair quality RCT found no significant improvement in quality of life following computer-assisted working memory training.

Reasoning
Not effective
2a

One fair quality RCT (Westerberg et al., 2007) investigated the effect of computer interventions on reasoning in patients with chronic stroke. This fair quality RCT randomized patients to receive home-based computer-assisted working memory training or no treatment. Reasoning skills were measured by Raven’s Progressive Matrices at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that a home-based computer-assisted working memory training is not more effective than no treatment in improving reasoning skills in patients with chronic stroke.

Self-perceived cognitive health
Effective
2a

Two fair quality RCTs (Westerberg et al., 2007; Lundqvist et al., 2010) investigated the effect of a computer intervention on self-perceived health in patients with chronic stroke.

The first fair quality RCT (Westerberg et al., 2007) randomized patients to receive home-based computer-assisted working memory training or no treatment. Self-perceptive health (self-rated cognitive failures) was measured by the Cognitive Failure Questionnaire at post-treatment (5 weeks). Significant between-group differences in cognitive failures were found, favoring computer-assisted working memory training vs. no treatment,

The second fair quality cross-over RCT (Lundqvist et al., 2010) randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Self-perceived health was measured by Visual Analogue Scale (VAS) at 20 weeks after training. Between-group differences in self-perceived health were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline to follow-up.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that home-based computer assisted working memory training is more effective than no treatment in improving self-perceived health in patients with chronic stroke. A second fair quality RCT also reported significant improvements in self-perceived health following computer-assisted working memory training.

Chronic phase - Paging system

Task completion
Effective
2a

One fair quality RCT (Fish et al., 2008) investigated the effect of electronic cueing using a paging system on task completion in patients with chronic stroke. This fair quality cross-over RCT randomized patients to receive pager training or delayed pager training (no training). Task completion was measured according to percentage of tasks successfully completed, taken at post-treatment (7 weeks) and at follow-up (7 weeks after pager withdrawal). Both groups demonstrated a significant between-group differences in task completion immediately following their respective intervention phase; results deteriorated to baseline levels following a period of non-use of the pagers.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the electronic cueing using a paging system is more effective than a comparison intervention (no pager training) in improving task completion in patients with chronic stroke, in the short term.

Chronic phase - Strategy training

Cognitive flexibility (self-reported)
Effective
2a

One fair quality RCT (Man et al., 2006) investigated the effect of strategy training on cognitive flexibility in patients with chronic stroke. This fair quality RCT randomized patients to receive strategy training in the form of online (videoconference) training, self-directed computer-assisted training, face-to-face therapist-directed training or no training. Self-reported cognitive flexibility was measured by the Problem-solving Self-Efficacy Scale at baseline and at post-treatment (20 treatment sessions over 2 months). Significant between-group differences were found at post-treatment, favoring face-to-face therapist training vs. online (videoconferencing) training, and favoring face-to-face therapist training vs. self-directed computer-assisted training.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that strategy training in the form of face-to-face therapist training is more effective than comparison interventions (online interactive problem-solving training, computer-assisted problem-solving training) in improving self-reported cognitive flexibility in patients with chronic stroke.

Concept formation ability
Not effective
2a

One fair quality RCT (Man et al., 2006) investigated the effect of strategy training on concept formation ability in patients with chronic stroke. This fair quality RCT randomized patients to receive strategy training in form of online (videoconferencing) training, self-directed computer-assisted training or face-to-face therapist-directed training, or no training. Concept formation ability was measured by the Category Test at baseline and at post-treatment (20 treatment sessions over 2 months). No significant differences were found between any groups.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that strategy training in the form of online interactive training, computer-assisted training or face-to-face therapist training is not more effective than no treatment in improving concept formation ability in patients with chronic stroke.

Instrumental activities of daily living (IADLs)
Not effective
2a

One fair quality RCT (Man et al., 2006) investigated the effect of strategy training on instrumental activities of daily living (IADLs) in patients with chronic stroke. This fair quality RCT randomized patients to receive strategy training in the form of online (videoconference) training, self-directed computer-assisted training or face-to-face therapist-directed training, or no training. IADLs were measured by the Chinese Version of the Lawton Instrumental Activities of Daily Living Scale at baseline and at post-treatment (20 treatment sessions over 2 months). No significant differences were found between any groups.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that strategy training in the form of online interactive training, computer-assisted training or face-to-face therapist training is not more effective than no treatment in improving IADLs in patients with chronic stroke.

Chronic phase - Virtual reality

Attention
Effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on attention in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Attention was measured by the Addenbrooke Cognitive Examination (ACE – Attention) at post-treatment (4-6 weeks). Significant between-group differences in attention were found at post-treatment, favoring VR-based rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving attention in patients with chronic stroke.

One fair quality RCT (Man et al., 2006) investigated the effect of strategy training on instrumental activities of daily living (IADLs) in patients with chronic stroke. This fair quality RCT randomized patients to receive strategy training in the form of online (videoconference) training, self-directed computer-assisted training or face-to-face therapist-directed training, or no training. IADLs were measured by the Chinese Version of the Lawton Instrumental Activities of Daily Living Scale at baseline and at post-treatment (20 treatment sessions over 2 months). No significant differences were found between any groups.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that strategy training in the form of online interactive training, computer-assisted training or face-to-face therapist training is not more effective than no treatment in improving IADLs in patients with chronic stroke.

Cognitive function
Effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on cognitive function in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Cognitive function was measured by the Addenbrooke Cognitive Examination (ACE – total score) and the Mini-Mental State Examination (MMSE) at post-treatment (4-6 weeks). Significant between-group differences were found in both measures of cognitive function at post-treatment, favoring VR-based rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving cognitive function in patients with chronic stroke.

Memory
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on memory in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Memory was measured by the Addenbrooke Cognitive Examination (ACE – Memory) at post-treatment (4-6 weeks). No significant between-group differences in memory were found at post-treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving memory in patients with chronic stroke.

Processing speed and complex attention
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR) -based rehabilitation on processing speed and complex attention in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Processing speed and complex attention were measured by the Trail Making Test A & B at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving processing speed and complex attention in patients with chronic stroke.

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on memory in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Memory was measured by the Addenbrooke Cognitive Examination (ACE – Memory) at post-treatment (4-6 weeks). No significant between-group differences in memory were found at post-treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving memory in patients with chronic stroke.

Reasoning
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on reasoning in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Logical/sequential reasoning was measured by the WAIS III Picture Arrangement test at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving reasoning in patients with chronic stroke.

Stroke outcomes
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR) -based rehabilitation on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Stroke outcomes measured by the Stroke Impact Scale at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving stroke outcomes in patients with chronic stroke.

Verbal fluency / language
Effective
1b

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR) -based rehabilitation on verbal fluency/language in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Verbal fluency/language was measured by the Addenbrooke Cognitive Examination (ACE – Fluency, Language) at post-treatment (4-6 weeks). At post-treatment there were significant between-group differences in ACE Fluency scores only, favoring VR-based rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving verbal fluency in patients with chronic stroke.
Note:
There were no significant between-group differences in language scores.

Visuospatial skills
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR)-based rehabilitation on visuospatial skills in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Visuospatial skills were measured by the Addenbrooke Cognitive Examination (ACE –Visuospatial) at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving visuospatial skills in patients with chronic stroke.

Phase not specific to one period - Cognitive Orientation to Daily Occupational Performance (CO-OP)

Cognitive flexibility
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on cognitive flexibility in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Cognitive flexibility was measured by the Delis-Kaplan Executive Function System (D-KEFS) Colour-Word Interference Test at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than a comparison intervention (computer-assisted working memory training) in improving cognitive flexibility in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Dysexecutive deficits
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on dysexecutive deficits in patients with stroke. The fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Dysexecutive deficits were measured by the Dysexecutive Questionnaire at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than comparison interventions (computer-based memory training) in improving dysexecutive deficits in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Life habits
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on life habits in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Life habits were measured by the Assessment of Life Habits at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than a comparison intervention (computer-assisted memory training) in improving life habits in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Occupational performance
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on occupational performance in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – performance and satisfaction scales for trained and untrained tasks/significant others’ ratings) and the Self-Efficacy Scale for Performing Life Activities Post-Stroke at post-treatment (8 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.
Note: The CO-OP group demonstrated significant within-group differences on most COPM – performance and satisfaction scores (trained and untrained tasks), and on the Self-Efficacy Scale for Performing Life Activities Post-Stroke at both time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than a comparison intervention (computer-assisted memory training) in improving occupational performance in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Processing speed and complex attention
Conflicting
4

Two fair quality RCTs (Poulin et al., 2016; Wolf et al., 2016) investigated the effect of the CO-OP treatment approach on processing speed and complex attention in patients with stroke.

The first fair quality partial RCT (Poulin et al., 2016) assigned patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Processing speed and complex attention were measured by the Trail Making Test A&B at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

The second fair quality RCT (Wolf et al., 2016) randomized patients with acute/subacute stroke to receive the CO-OP treatment approach or conventional occupational therapy. Processing speed and complex attention was measured by the Delis-Kaplan Executive Function System Trail Making Test at baseline, at post-treatment (10 weeks) and at follow-up (3 months). Change scores from baseline to post-treatment and baseline to follow-up revealed medium effect sizes, favoring CO-OP vs. conventional occupational therapy.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of the CO-OP approach on processing speed and complex attention in patients with stroke. One fair quality partial RCT found that an 8-week CO-OP training program was not more effective than computer-assisted working memory training, whereas a second fair quality RCT found that a 10-week CO-OP training program was more effective than conventional rehabilitation.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Stroke outcomes
Effective
2a

One fair quality RCT (Wolf et al., 2016) investigated the effect of cognitive rehabilitation using the CO-OP approach on stroke outcomes in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive the CO-OP treatment approach or conventional occupational therapy. Stroke outcomes were measured by the Stroke Impact Scale (SIS – ADLs, Mobility, Hand Function, Strength, Recovery, Memory, Emotion, Communication, Physical) at post-treatment (10 sessions) and at follow-up (3 months). Change scores from baseline to post-treatment revealed medium to large effect sizes for most stroke outcomes (Recovery, ADLs, Hand Function, Strength, Communication, Memory, Emotion, Physical), favoring CO-OP vs. conventional occupational therapy. At follow-up, medium to large effect sizes were maintained in two stroke outcomes (Hand Function, Communication), favoring CO-OP vs. conventional occupational therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the CO-OP approach is more effective than a comparison intervention (conventional occupational therapy) in improving stroke outcomes in patients with stroke.

Working memory
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on working memory in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Working memory was measured by the Wechsler Adult Intelligence Scale-IV (WAIS-IV) Digit Span test at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than a comparison intervention (computer-assisted memory training) in improving working memory in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Phase not specific to one period - Computer interventions

Cognitive flexibility
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of a computer intervention on cognitive flexibility in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Cognitive flexibility was measured by the Delis-Kaplan Executive Function System (D-KEFS) Colour-Word Interference Test at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-assisted working memory training is not more effective than a comparison intervention (CO-OP treatment approach) in improving cognitive flexibility in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Cognitive function
Not effective
1b

One high quality RCT (Prokopenko et al., 2013) and one fair quality RCT (Akerlund et al., 2013) investigated the effect of computer interventions on cognitive function in patients with stroke.

The high quality RCT (Prokopenko et al., 2013) randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. Cognitive function was measured by the Mini-Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MOCA) at post-treatment (2 weeks). No significant between-group differences were found on either measure of cognitive functions.

The fair quality RCT (Akerlund et al., 2013) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training with conventional rehabilitation or conventional rehabilitation alone. Cognitive function was measured by the Barrow Neurological Institute Screening for Higher Cerebral Functions at baseline, at post-treatment (1 week following a 5-week treatment), and at follow-up (18 weeks, 24 weeks). Significant between-group differences were found in changes of cognitive function scores from baseline to post-treatment, favoring computer-assisted working memory training with conventional rehabilitation vs. conventional rehabilitation alone. Results did not remain significant at either follow-up time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer-assisted attention and working memory training is not more effective than a comparison intervention (conventional therapy) in improving cognitive function in patients with acute/subacute stroke. However, one fair quality RCT found that computer-assisted working memory training with conventional rehabilitation was more effective than conventional rehabilitation alone in improving cognitive function in patients with subacute/chronic stroke.
Note:
Differences in the type and duration of the intervention and outcome measures used may account for the discrepancy in results between studies.

Dysexecutive deficits
Not effective
2a

Two fair quality RCTs (Akerlund et al., 2013; Poulin et al., 2016) investigated the effect of computer training on dysexecutive deficits in patients with stroke.

The first fair quality RCT (Akerlund et al., 2013) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training with conventional rehabilitation or conventional rehabilitation alone. Dysexecutive deficits were measured by the Dysexecutive Questionnaire at post-treatment (1 week following a 5-week treatment) and at follow-up (18 weeks, 24 weeks). No significant between-group differences in dysexecutive deficits were found at any time point.

The second fair quality partial RCT (Poulin et al., 2016) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Dysexecutive deficits were measured by the Dysexecutive Questionnaire at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs that computer-assisted memory training is not more effective than comparison interventions (conventional rehabilitation alone, CO-OP) in improving dysexecutive deficits in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Frontal lobe function
Effective
1b

One high quality RCT (Prokopenko et al., 2013) investigated the effect of a computer intervention on frontal lobe function in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. Frontal lobe function was measured by the Frontal Assessment Battery at post-treatment (2 weeks). Significant between-group differences were found at post-treatment, favoring computer-assisted attention and working memory training vs. conventional therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer-assisted attention training is more effective than a comparison intervention (conventional therapy) in improving frontal lobe function in patients with stroke.

Life habits
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of a computer intervention on life habits in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Life habits were measured by the Assessment of Life Habits at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-assisted working memory training is not more effective than a comparison intervention (CO-OP) in improving life habits in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Mood
Not effective
1b

One high quality RCT (Prokopenko et al., 2013) and one fair quality RCT (Akerlund et al., 2013) investigated the effect of computer interventions on mood in patients with stroke.

The high quality RCT (Prokopenko et al., 2013) randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. Mood was measured by Hospital Anxiety and Depression Scale (HADS – Anxiety, Depression) at post-treatment (2 weeks). No significant between-group differences were found.

The fair quality RCT (Akerlund et al., 2013) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training with conventional rehabilitation or conventional rehabilitation alone. Anxiety and depression were measured by the HADS (Anxiety, Depression) at post-treatment (1 week following a 5-week treatment) and at follow-up (18 weeks, 24 weeks). There were no significant differences in anxiety at any time point or between intervention and control groups. There was a significant between-group difference in depression at post-treatment, favoring computer-assisted training group vs. conventional rehabilitation alone (Group C1, see below). Differences did not remain significant at either follow-up time point.
Note: The control group was subsequently offered computer training at the end of the study and results were analysed according to individuals who sought the intervention (Group C1) and those who refused the intervention (Group C2). Group C1 presented with significantly more depressive symptoms vs. Group C2 at baseline.

Conclusion: There is moderate evidence (Level 1b) from one high and one fair quality RCT that computer-assisted working memory training is not more effective than a comparison intervention (conventional rehabilitation alone) in improving mood in patients with stroke.

Occupational performance
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of a computer intervention on occupational performance in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – performance and satisfaction scales for trained and untrained tasks/significant others’ ratings) and the Self-Efficacy Scale for Performing Life Activities Post-Stroke) at post-treatment (8 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-assisted working memory training is not more effective than a comparison intervention (CO-OP) in improving occupational performance in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Processing speed and complex attention
Effective
1b

One high quality RCT (Prokopenko et al., 2013) and one fair quality RCT (Poulin et al., 2016) investigated the effect of a computer intervention on processing speed and complex attention in patients with stroke.

The high quality RCT (Prokopenko et al., 2013) randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. Attention was measured by Shulte’s Table at post-treatment (2 weeks). Significant between-group differences in attention were found at post-treatment, favoring computer-assisted attention training vs. conventional therapy.

The fair quality partial RCT (Poulin et al., 2016) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Processing speed and complex attention were measured by the Trail Making Test A&B at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer-assisted working memory training is more effective than a comparison intervention (conventional therapy) in improving processing speed and complex attention in patients with acute/subacute stroke. However, a fair quality RCT did not find any between-group differences on attention in patients witch acute/subacute stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Unilateral spatial neglect
Effective
1b

One high quality RCT (Prokopenko et al., 2013) investigated the effect of a computer intervention on unilateral spatial neglect (USN) in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. USN was measured by the Clock Drawing Test at post-treatment (2 weeks). Significant between-group differences in USN were found at post-treatment, favoring computer-assisted attention training vs. conventional therapy.

Conclusion: There is moderate evidence (Level 1b) that computer-assisted attention training is more effective than a comparison intervention (conventional therapy) in improving USN in patients with acute/subacute stroke.

Working memory
Not effective
2a

Two fair quality RCTs (Akerlund et al., 2013; Poulin et al., 2016) investigated the effect of computer interventions on working memory in patients with stroke.

The first fair quality RCT (Akerlund et al., 2013) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training with conventional rehabilitation or conventional rehabilitation alone. Working memory was measured by the Wechsler Adult Intelligence Scale-III NI (Digit Span: forwards, reversed, scaled; Span Board: forwards, reversed, scaled; Working memory scaled score) at baseline, at post-treatment (1 week following a 5-week treatment) and at follow-up (18 weeks, 24 weeks). There were no significant between-group differences on any measure of working memory at post-treatment. At follow-up (18 weeks only) there were significant between-group differences in two measures of working memory (WAIS III NI – Digit Span forward, reversed change scores from baseline), favoring computer-assisted working memory training with conventional rehabilitation vs. conventional rehabilitation alone.

The second fair quality partial RCT (Poulin et al., 2016) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or CO-OP treatment approach. Working memory was measured by the WAIS-IV Digit Span test at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs that computer-assisted working memory training is not more effective than comparison interventions (conventional rehabilitation alone, CO-OP treatment approach) in improving working memory in patients with stroke. However, one fair quality RCT found that working memory training did improve at follow-up only, in favour of computer-assisted working memory training with conventional rehabilitation vs. conventional rehabilitation alone.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Phase not specific to one period - Strategy training

Cognitive flexibility
Effective
1b

One high quality RCT (Skidmore et al., 2015a) investigated the effect of strategy training using the Canadian Occupational Performance Measure (COPM) on cognitive flexibility in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive COPM strategy training or attention training for the duration of hospitalization (approx. 1-3 weeks). Cognitive flexibility was measured by the Delis-Kaplan Executive Functioning System (D-KEFS) Color Word Interference Test (cognitive flexibility scale) at 3 and 6 months after study admission. Significant between-group differences in cognitive flexibility were found at both follow-up time points, favoring COPM strategy training vs. attention training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that strategy training using the COPM is more effective than a comparison intervention (attention training) in improving cognitive flexibility in patients with stroke.

Functional independence
Effective
1b

One high quality RCT (Skidmore et al., 2015a) investigated the effect of strategy training using the Canadian Occupational Performance Measure (COPM) on functional independence in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive COPM strategy training or attention training for the duration of hospitalization (approx. 1-3 weeks). Functional independence was measured by the Functional Independence Measure (FIM) at 3 and 6 months after study admission (follow-up). Significant between-group differences in functional independence were found at both follow-up time points, favoring COPM strategy training vs. attention training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that strategy training using the COPM is more effective than a comparison intervention (attention training) in improving functional independence in patients with stroke.

Inhibition
Not effective
1b

One high quality RCT (Skidmore et al., 2015a) investigated the effect of strategy training using the Canadian Occupational Performance Measure (COPM) on inhibition in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive COPM strategy training or attention training for the duration of hospitalization (approx. 1-3 weeks). Inhibition was measured by the Delis-Kaplan Executive Functioning System (D-KEFS) Color Word Interference Test (inhibition scale) at 3 and 6 months after study admission. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that strategy training using the COPM is not more effective than a comparison intervention (attention training) in improving inhibition in patients with stroke.

Mood
Effective
1b

A secondary analysis (Skidmore et al., 2015b) of one high quality RCT (Skidmore et al., 2015a) investigated the effect of strategy training using the Canadian Occupational Performance Measure (COPM) on apathy in patients with stroke. The high quality RCT (Skidmore et al., 2015a) randomized patients with acute/subacute stroke to receive strategy training using the COPM or attention training for the duration of hospitalization (approx. 1-3 weeks duration). Apathy was measured by the Apathy Evaluation Scale at 3 and 6 months after study admission. Significant between-group differences in apathy were found at 3 months after study admission only, favoring strategy training using the COPM vs. attention training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that strategy training using the COPM is more effective than a comparison intervention (attention training) in improving apathy in patients with acute/subacute stroke.

Phase not specific to one period - Time pressure management

Cognitive function
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on cognitive function in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Cognitive impairment was measured by the Symbol Digit Modalities Test at post-treatment (10 hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving cognitive impairment in patients with stroke.

Fatigue
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on fatigue in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Fatigue was measured by the Fatigue Severity Scale at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving fatigue in patients with stroke.

Functional independence
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on functional independence in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional therapy. Functional independence was measured by the Barthel Index at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving functional independence in patients with stroke.

Information intake
Effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on information intake in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Information intake was measured by an information intake task (no. of strategies used, reproduction scores) at post-treatment (10 hours of treatment) and at follow-up (3 months). Significant between-group differences in information intake (no. of used strategies) were found at post-treatment, favoring time pressure management training vs. conventional therapy. These between-group differences were not maintained at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is more effective than a comparison intervention (conventional therapy) in improving information intake in patients with stroke.

Inhibition / attention
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on inhibition/attention in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Inhibition/attention was measured by the Stroop Color Word Task at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving inhibition /attention in patients with stroke.

Mental slowness processing
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on mental slowness processing in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Mental speed was measured by the Mental Slowness Observation Test (MSOT – no. of used strategies, no. of correct elements, time), and perceived consequence of mental slowness was measured by the Mental Slowness Questionnaire. Measures were taken at post-treatment (10 hours of treatment) and at follow-up (3 months). There were no significant between-group differences on either measure at post-treatment. There was a significant between-group difference in one measure of mental speed (MSOT – time) at follow-up, favoring time pressure management vs. conventional therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving mental speed in patients with stroke. However, there was a long-term benefit resulting from time pressure management training.

Mood
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on depression in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Depression was measured by the Center for Epidemiologic Studies Depression Scale at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving depression in patients with stroke.

Processing speed and complex attention
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on processing speed and complex attention in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Processing speed and complex attention were measured by the Trail Making A & B Test at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving processing speed and complex attention in patients with stroke.

Quality of life
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on quality of life in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Quality of life was measured by the EuroQol-5D at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving quality of life in patients with stroke.

Working memory
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on working memory in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional therapy. Working memory was measured by the Rey Auditory Verbal Learning Test and the Paced Auditory Serial Addition Test at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found on either measure of working memory at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving working memory in patients with stroke.

Phase not specific to one period - Virtual reality

Attention
Effective
2b

One poor quality RCT (Gamito et al., 2017) investigated the effect of virtual-reality (VR)-based rehabilitation on attention in patients with stroke. This poor quality RCT randomized patients (stage of stroke not specified) to receive immediate VR-based cognitive rehabilitation or delayed VR-based cognitive rehabilitation (no training). Attention was measured by the Toulouse-Pieron Test (work efficiency) at post-treatment (4-6 weeks). Significant between-group differences in attention were found at post-treatment, favoring VR-based cognitive rehabilitation vs. no training.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that VR-based cognitive rehabilitation is more effective than no training in improving attention in patients with stroke.

Working memory
Effective
2b

One poor quality RCT (Gamito et al., 2017) investigated the effect of virtual-reality (VR)-based rehabilitation on working memory in patients with stroke. This poor quality RCT randomized patients (stage of stroke not specified) to receive immediate VR-based cognitive rehabilitation or delayed VR-based cognitive rehabilitation (no training). Working memory was measured by the Wechsler Memory Scale (WMS – total score) and the Rey-Osterrieth Complex Figure test (ROCF – Immediate recall) at post-treatment (4-6 weeks). There were significant between-group differences in one measure of working memory (WMS total score) at post-treatment, favoring VR-based cognitive rehabilitation vs. no training.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that VR-based cognitive rehabilitation is more effective than no training in improving working memory in patients with stroke.

Clinician How-To

Executive function e-learning module

Please visit our Executive function e–learning module: http://strokengine.org/elearning/executivefunction/module.php

What is executive function (EF)?

Executive function refers to “high-level cognitive functions that provide control and direction of lower-level, more automatic functions” (Stuss, 2009, p. 8) and encompasses cognitive processes including:
initiation,
planning,
sequencing,
monitoring,
problem-solving,
divided attention,
flexibility,
working memory,
inhibition and
judgement/decision-making
(Anderson, 2008; Godefroy & Stuss, 2007; Lezak, 1989; Stuss, 2009).

Which parts of the brain are involved in EF?

The frontal lobes of the brain, especially the prefrontal cortex (i.e. the part of the frontal lobes located just behind the forehead), are known to be highly involved in executive functioning (Stuss, 2009). Executive functions can also be impaired by diffuse brain lesions and various network disconnections resulting from white matter damage or impairment to other brain regions (Stuss et al., 2002).

Please see the following website for further information on brain anatomy (including pictures of the brain lobes):
http://thebrain.mcgill.ca/flash/d/d_01/d_01_cr/d_01_cr_ana/d_01_cr_ana.html

What are the potential consequences of EF problems?

Which executive function abilities are affected? Potential impact on everyday activities
Initiation:

The ability to spontaneously start a task or activity (Grieve & Gnanasekaran, 2008)

  • Poor self-care unless prompted
  • Requires prompting to start household tasks (e.g. cleaning, laundry, watering the plants, etc…)
  • Difficulty initiating conversation with other people
  • Difficulty keeping in touch with friends or family (e.g. the person no longer calls family members or friends as he/she used to do)
  • Poor participation in leisure activities (e.g. sitting around at home most of the day long and watching TV)
Planning:

“Planning ability involves anticipating future events, formulating a goal or endpoint, and devising a sequence of steps or actions that will achieve the goal or endpoint” (Anderson, 2008, p. 17)

  • Reduced efficiency/competence in achieving daily tasks (e.g. self-care, meal preparation, grocery shopping, etc…)
  • Difficulty planning meals (e.g. difficulty identifying alternatives and selecting the most appropriate alternative according to their particular needs, taste, available ingredients, etc…)
  • Difficulty meeting deadlines (e.g. at work or for bill payment)
  • Difficulty scheduling and keeping appointments
Sequencing:

“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))

  • Dressing in usual order (e.g. putting on shoes before pants)
  • Transferring from wheelchair to bed
  • Taking a shower (e.g. turning off the water before rinsing off all the soap)
  • Meal preparation (e.g., putting pasta in the pot before the water boils)
Problem-solving: “Goal-directed cognitive activity that arises in situations for which no response is immediately apparent or available” (Luria, 1966; as cited in (Rath et al., 2004))
  • Unable to deal with unforeseen problems (e.g. losing wallet, losing keys, car breakdown)
  • May need supervision and/ or assistance for making a major purchase (e.g. furniture) or for financial planning
  • May have difficulty operating new electrical appliances
  • Difficulty applying newly learned skills to new situations or unfamiliar environments (e.g. using a public toilet in the mall versus at home)
Monitoring:

“The process of checking the task over time for ‘quality control’ and the adjustment of behavior” (Stuss, 2009, p. 9-10)

  • Difficulty perceiving and/or correcting errors while performing a task (e.g. buying the wrong items at the grocery store, letting the cake burn or not letting it cook long enough, etc…)
  • Difficulty following instructions (e.g. the person stops referring to the written plan or is disrupted by environmental stimuli)
Inhibition:

The ability to suppress automatic actions that are inappropriate in a given context that interfere with a certain behavior (Grieve & Gnanasekaran, 2008)

  • Social relationships and conversations with other people are affected by doing or saying embarrassing things
  • Driving: A driver with reduced inhibition may see a traffic light and come to a complete stop, yet the light is green. Or, he may come to a complete stop at the warning sign of a stop sign ahead.
Working memory: Executive process responsible for the temporary storage and manipulation of information in both simple (e.g. recalling a series of digits such as a phone number) and complex cognitive tasks (e.g. coordinating two tasks simultaneously) (Van der Linden, 2007)
  • Difficulty understanding and reading long sentences
  • Holding a conversation involving several persons
  • Using the phone (e.g. recalling and dialling a phone number)
  • Grocery shopping (e.g. the person forgets some of the items he/she had put in the shopping cart and has to check if indeed the item is already in the cart; difficulty manipulating money for shopping)
  • Leisure activities that involve the visual and spatial organisation of items or keeping the score” (e.g. playing board games / puzzles / cards) (Grieve & Gnanasekaran, 2008)
Divided attention:

“The allocation of attentional resources across more than one task” (Ponsford, 2008, p. 514)

  • Talking to a friend while walking/driving
  • Meal preparation (e.g. chopping vegetables while periodically checking food on the stove)
  • Group meetings at work
  • Looking after young children while preparing supper
  • Driving (e.g. integrating information from different targets such as a pedestrian on the sidewalk, an upcoming traffic light and the proximity of another vehicle; all while maintaining proper vehicle positioning and speed)
  • Crossing busy streets while watching for any cars and moving through dense pedestrian traffic
Flexibility:

The ability to shift between different thoughts and actions so that when a problem arises, one can draw upon past mistakes and successes and use this knowledge to plan solutions (Anderson, 2008)

  • Playing games / cards (e.g. a person lacking mental flexibility may have difficulty changing his/her strategies in response to the actions of other players)
  • Conversations with a group of people (e.g. difficulty shifting from topic to topic in conversation)
  • Meal preparation that requires multiple task switching
  • Driving (e.g. a driver lacking mental flexibility may come to a complete stop by slamming on the brakes when faced with an unexpected obstruction on a one-way street that he is used to driving on and may have difficulty finding a quick alternative solution).
Judgement / decision-making:

The assessment and ‘ordering of various competing actions and goals’ (Barnes & Thagard, 1996)

  • Avoiding unsafe situations when cooking, taking a bath, crossing busy streets, driving, etc…
  • Following treatment instructions / therapists’ recommendations (e.g. using a wheelchair to move around)
  • Inappropriate choice of clothes (not taking into consideration weather, context, etc…)

Why is it critical to assess EF post-stroke?

Disorders in EF after stroke are very common and affect participation in rehabilitation (Skidmore et al., 2010) and recovery (Lesniak, Bak, Czepiel, Seniow & Czlonkowska, 2008) with high risk of functional dependence (Lesniak et al., 2008), failure to return to work (Ownsworth & Shum, 2008) and poor social participation (McDowd, Filion, Pohl, Richards & Stiers, 2003).

Given that executive dysfunction can result in serious functional limitations, and that promising interventions exist for EF rehabilitation, all patients should be quickly screened or assessed for EF problems post-stroke. Patients identified with the presence of EF problems should receive interventions aimed at reducing impairment and/or maximizing everyday functioning.

Who should be assessed?

Disorders in EF are common cognitive sequelae of stroke, with reported occurrence in 19 to 75 percent of patients (Lesniak et al., 2008; Riepe, Riss, Bittner & Huber, 2004; Zinn, Bosworth, Hoenig & Swartzwelder, 2007). The complexity of EF makes them very sensitive to brain changes resulting from stroke (Levine et al., 2008). Thus, routine screening for EF problems in persons with stroke is important.

Can EF problems be treated?

There are three different treatment approaches for EF deficits after a stroke. They aim to:

  1. Restore the EF abilities that have been affected by a stroke;
  2. Teach cognitive strategies to compensate for EF abilities that have been affected by the stroke;
  3. Teach the use of external aids and environmental modifications

These approaches are described below.

 

  1. Restoring EF abilities that have been affected by strokeThese interventions are oriented toward targeted remediation of specific EF abilities, for example, through retraining on computer-based tasks or face-to-face training with a therapist.Specific interventions have recently been developed and used with people with stroke including:
    • Computerized training for working memory (Lundqvist et al., 2010; Westerberg et al., 2007):
      • Tasks involve presentations of auditory and visuo-spatial stimuli.
      • Treatment schedule: 40 to 60 minute sessions, 5 days per week for 5 weeks.
    • Computerized dual-task training (Stablum et al., 2000):
      • Tasks involve coordinating the execution of 2 responses; patients have to identify the position (right or left) of 2 letters on the computer screen, and determine whether the 2 letters are the same or different
      • Treatment schedule: 1 session per week for 5 weeks.
    • Verbal working memory training (Vallat et al., 2005):
      • Face-to-face training using activities such as word spelling or sorting a series of words into alphabetic order.
      • Treatment schedule: 60 minute sessions, 3 days per week over 6 months.
  2. Teaching cognitive strategies to compensate for EF abilities affected by strokeThis may involve learning and applying strategies to solve everyday difficulties and to handle everyday situations in a more structured way.Specific interventions have recently been developed and used with people with stroke including:
    • Analogical problem-solving training (Man et al., 2006):
      • Patients are presented with common everyday problems and are taught to draw analogies to solve similar problems (Man et al., 2006).
      • Treatment schedule: 20 sessions of 45 minutes.

      NOTE: The use of problem solving strategies was also incorporated in small pilot studies using different training tasks and procedures (Honda, 1999; Rand et al., 2009).

    • Goal Management Training (GMT) (Levine et al., 2011; Schweizer et al., 2008):
      • Patients learn to periodically stop ongoing behaviour in order to reflect on the goal and the subgoals of their task and self-monitor their performance. This training consists of instructional material, interactive tasks, discussion of patients’ real-life difficulties, and homework assignments.
      • Treatment schedule: weekly 2-hour sessions over 7 weeks.
      • Please visit the http://research.baycrest.org/gmt for more information on the administration of GMT; a GMT video is also available on this website.
    • Cognitive Orientation to daily Occupational Performance (CO-OP) approach (Polatajko & Mandich, 2004):
      • “CO-OP is a client-centred, performance-based, problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery” (Polatajko & Mandich, 2004, p. 2). Clients learn to use a global problem-solving strategy to perform self-identified functional tasks that they want to improve. The therapist guides the client to discover solutions to their performance problems; the intervention is conducted through talking about plans and strategies for skill acquisition, through doing functional tasks and/or through homework.
      • Treatment schedule: 10 to 20 sessions lasting 45-60 minutes each
      • Please visit the http://www.ot.utoronto.ca/coop/index.html for more information on the CO-OP approach.
  3. Teaching the use of external aids or environmental modificationsThis may involve using external aids (e.g. paging systems and task-specific checklists) or other environmental modifications in an attempt to improve performance of daily activities.As you read the short vignette below, try to think of external compensatory strategies that you would typically use to help this client compensate for her difficulties and to facilitate the accomplishment of her everyday activities.Mrs. P who had her stroke 4 months ago is now home and is walking around her apartment and dressing herself with reminders from her husband. He is concerned that she has not resumed her usual activities – playing bingo, gardening, calling her best friend in the morning to touch base about going for a walk, etc. While Mrs. P’s physical recovery has been good and her husband is thankful to have her at home, he is finding her “not like she used to be” in terms of the way she thinks and initiates activities. He has asked for a home visit by an occupational therapist to help Mrs. P get back her “old habits and activities”.

Below are examples of different external compensatory strategies that can be used to improve performance of daily activities in persons with EF problems.

 

Which executive function abilities are affected? Potential impact on everyday activities External compensatory strategies
Initiation:

The ability to spontaneously start a task or activity (Grieve & Gnanasekaran, 2008)

  • Poor self-care unless prompted
  • Requires prompting to start household tasks (e.g. cleaning, laundry, watering the plants, etc…)
  • Difficulty initiating conversation with other people
  • Difficulty keeping in touch with friends or family (e.g. the person no longer calls his/her family members or friends as he/she used to do)
  • Poor participation in leisure activities (e.g. sitting around at home most of the day long and watching TV)
  • External cues/reminders:
    • Electronic paging systems (Evans et al., 1998; Fish et al., 2008a,b)
    • Alarm watches (Zoltan, 2007)
    • Mobile phones & smartphones
  • To-do lists

  • Visual cues in the person’s environment (e.g. keeping a laundry basket filled with clothes that need to be washed in a visible place)
  • Reminders / cues from significant others
  • Developing a daily routine (Zoltan, 2007)
Planning:

“Planning ability involves anticipating future events, formulating a goal or endpoint, and devising a sequence of steps or actions that will achieve the goal or endpoint” (Anderson, 2008, p. 17)

  • Reduced efficiency/competence in achieving daily tasks (e.g. self-care, meal preparation, grocery shopping, etc…)
  • Difficulty planning meals (e.g. difficulty identifying alternatives and selecting the most appropriate alternative according to their particular needs, taste, available ingredients, etc…)
  • Difficulty meeting deadlines (e.g. at work or for bill payment)
  • Difficulty scheduling and keeping appointments
  • Appointment calendars (Zoltan, 2007)
  • Checklists of steps to be done (Evans et al., 1998; Fish et al., 2008a)
  • Step by step directions / written instructions
  • Timers with auditory / verbal reminders
  • Reorganizing the client’s living environment (e.g. separate shelves for each category of items, written labels, etc…) (Zoltan, 2007)
Sequencing:

“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in Baum, Morrison, Hahn & Edwards, 2007)

  • Dressing in usual order (e.g., putting on shoes before pants)
  • Transferring from wheelchair to bed
  • Taking a shower (e.g. turning off the water before rinsing off all the soap)
  • Meal preparation (e.g., putting pasta in the pot before the water boils)
  • Step by step written directions and/or sequence of visually illustrated steps
  • Adapt the client’s environment: “arrange items according to the sequence of use before starting a task” (Zoltan, 2007, p. 256) (e.g. laying out clothes on the bed before dressing)
  • Cues from family/carers
Problem-solving: “Goal-directed cognitive activity that arises in situations for which no response is immediately apparent or available” (Luria, 1966; as cited in Rath et al., 2004)
  • Unable to deal with unforeseen problems (e.g. losing wallet, losing keys, car breakdown)
  • May need supervision and/ or assistance for making a major purchase (e.g. furniture) or for financial planning
  • May have difficulty operating new electrical appliances
  • Difficulty applying newly learned skills to new situations or unfamiliar environments (e.g. using a public toilet in the mall versus at home)
  • Step-by-step written instructions
  • Cues from family/carers
  • Delegate responsibilities to other family members
  • Adapt the client’s environment to facilitate problem-solving (e.g. limit irrelevant visual and/or auditory information) (Zoltan, 2007)
Monitoring:

“The process of checking the task over time for ‘quality control’ and the adjustment of behavior” (Stuss, 2009, p. 9-10)

  • Difficulty perceiving and/or correcting errors while performing a task (e.g. buying the wrong items at the grocery store, letting the cake burn or not letting it cook long enough, etc…)
  • Difficulty following instructions (e.g. the person stops referring to the written plan or is disrupted by environmental stimuli)
  • Auditory cues to remind the person to self-monitor his/her behavior (Manly et al., 2002) (e.g. timers, smartphone functions, pagers)
  • Alarms (e.g. reminder-alarms in kitchen equipment)
  • Checklists (e.g. the person has to tick off each step once it has been done)
  • Reminders / cues from family/carers
Inhibition:

The ability to suppress automatic actions that are inappropriate in a given context that interfere with a certain behavior (Grieve & Gnanasekaran, 2008)

  • Social relationships and conversations with other people are affected by doing or saying embarrassing things
  • Driving: A driver with reduced inhibition may see a traffic light and come to a complete stop, yet the light is green. Or, he may come to a complete stop at the warning sign of a stop sign ahead.
  • Verbal prompts or cues from family/carers
Working memory: Executive process responsible for the temporary storage and manipulation of information in both simple (e.g. recalling a series of digits such as a phone number) and complex cognitive tasks (e.g. coordinating two tasks simultaneously) (Van der Linden, 2007)
  • Difficulty understanding and reading long sentences
  • Holding a conversation involving several persons
  • Using the phone (e.g. recalling and dialling a phone number)
  • Grocery shopping (e.g. the person forgets some of the items he/she had put in his shopping cart and has to check if indeed the item is already in the cart; difficulty manipulating money for shopping)
  • Leisure activities that involve the visual and spatial organisation of items or keeping the score” (e.g. playing board games / puzzles / cards) (Grieve & Gnanasekaran, 2008)
  • Note taking (brief and in point form)
  • Checklists / step by step written instructions
  • Audio taping / digital recorders (to record and replay important material)
  • Speed dialling buttons on the telephone, smartphones
  • Reminders from significant others
Divided attention:

“The allocation of attentional resources across more than one task” (Ponsford, 2008, p. 514)

  • Talking to a friend while walking/driving
  • Meal preparation (e.g. chopping vegetables while periodically checking food on the stove)
  • Group meetings at work
  • Looking after young children while preparing supper
  • Driving (e.g. integrating information from different targets such as a pedestrian on the sidewalk, an upcoming traffic light and the proximity of another vehicle; all while maintaining proper vehicle positioning and speed)
  • Crossing busy streets while watching for any cars and moving through dense pedestrian traffic
  • “Reduce distractions (e.g., work in a quiet room, […], reduce interruptions and background noise, clear workspace)” (Ponsford, 2008, p. 516)
  • “Tasks may be modified to reduce speed demands or the amount of information to be processed” (Ponsford, 2008, p. 516) [e.g., going to the mall during weekdays and/or when there is low traffic]
  • Attempt one task completely prior to initiating another
  • Allocate enough time to complete the tasks one at a time in sequence
  • “More complex tasks may be scheduled at the time of the day when fatigue levels are lower” (Ponsford, 2008, p. 516)
  • Verbal prompts or cues from family/carers
Flexibility:

The ability to shift between different thoughts and actions so that when a problem arises, one can draw upon past mistakes and successes and use this knowledge to plan solutions (Anderson, 2008)

  • Playing games / cards (e.g. a person lacking mental flexibility may have difficulty changing his/her strategies in response to the actions of other players)
  • Conversations with a group of people (e.g. difficulty shifting from topic to topic in conversation)
  • Financial planning
  • Meal preparation that requires multiple task switching
  • Driving (e.g. a driver lacking mental flexibility may come to a complete stop by slamming on the brakes when faced with an unexpected obstruction on a one-way street that he is used to driving on and may have difficulty finding a quick alternative solution).
  • Verbal prompts or cues from family/carers to assist the person to move from one task to the other
  • Delegate some previously held responsibilities to other family members
  • Step-by-step written instructions (to assist the person to move from one task to the other)
Judgement / decision-making:

The assessment and ‘ordering of various competing actions and goals’ (Barnes & Thagard, 1996)

  • Avoiding unsafe situations when cooking, taking a bath, crossing busy streets, driving, etc…
  • Following treatment instructions / therapists’ recommendations (e.g. using a wheelchair to move around)
  • Inappropriate choice of clothes (not taking into consideration weather, context, etc…)
  • Written guidelines and/or visual cues
  • Sensors and alarms (e.g. chair sensor pad with alarm, reminder-alarms in kitchen equipment)
  • Automatic controls (e.g. heating, shower water temperature, etc…)
  • Adapt the client’s environment to facilitate decision-making / limit irrelevant information (e.g. only keep clothes that are relevant to the season in the closet)
  • Supervision or assistance from a caregiver

Which EF treatments work?

A systematic literature review on the effectiveness of EF interventions post-stroke was conducted in January 2011 (please see the paper from Poulin, V., Korner-Bitensky, N., Dawson, D., & Bherer, L. (2012). Efficacy of executive function interventions after stroke: a systematic review. Topics in Stroke Rehabilitation, 19(2), 158-171) and was updated in February 2013 for the purpose of this module.

Twelve studies met inclusion criteria, 1 evaluating treatment in the subacute stage of stroke recovery (using a pre-post controlled group design) and 11 in the chronic stage (including 4 fair quality randomized controlled trials (RCT), 1 controlled group study, 4 single-subject design studies and 2 pre-post design studies). At this early stage of research there is limited evidence at the subacute (level 2b) and chronic (level 2a) stages of stroke recovery supporting the use of remedial (e.g. computerized working memory training) and compensatory interventions (e.g. problem-solving strategies, paging system) for improving executive functioning and, possibly, functional abilities.

Intervention Findings Level of Evidence
Problem-solving training Effective 2a
Cognitive orientation to daily occupational performance (CO-OP)*

– impact on executive functioning

No evidence 5
Computerized dual-task training Effective 2b
Computerized working memory training Effective 2a
Goal management training Effective 2b
Paging system Effective 2a
Smartphone applications** No evidence 5
Task-specific checklists Effective 2b

 

*Several pilot studies have reported improvements in motor and functional skills for persons with chronic stroke (Henshaw et al., 2011; McEwen et al., 2009, 2010a, 2010b; Polatajko et al., 2012) and acute stroke (Skidmore et al., 2011) receiving the Cognitive orientation to daily occupational performance (CO-OP) intervention. The impact of CO-OP on measures of EF has not been specifically examined in previous studies, but some trials are currently being conducted to address this question.

** Further research is needed to evaluate the effectiveness of new technologies (e.g. smartphone applications).

When is the best time to receive treatments for EF problems?

EF interventions can be provided during the acute, subacute, and chronic stages post-stroke.

What type of client is EF treatment for?

EF treatment can be offered to individuals of all ages with mild, moderate or severe EF deficits but should be carefully matched to the patient’s deficits, residual strengths and goals. Clients must be able to understand instructions and follow simple commands. Some interventions also require that clients have sufficient expressive language abilities to verbalize strategies and sufficient insight to be able to identify some day-to-day difficulties they want to improve. The therapist may have to adapt some of the training tasks according to the client’s cognitive, motor or linguistic impairments.

Please see the short vignettes below regarding two patients with executive dysfunction and how the clinician adapted therapy to suit their needs.

Mr G, a 55 years old engineer who had a left middle cerebral artery stroke 2 months ago, is presenting with mild EF problems, minor aphasic impairment and right sided weakness. He has now resumed most of his previous daily activities, except for driving and working. Also, it is still difficult for him to:

  • hold a conversation involving several persons
  • remember codes and phone numbers
  • perform two tasks simultaneously (e.g. taking notes while talking on the phone)

He is currently participating in a computer-based EF training program, in addition to other rehabilitation interventions.

Clinician management: His therapist selected computer-based tasks that target working memory and high-level attention (also see the Review of computer-based programs and videogames for executive function retraining). The therapist carefully analyzed the computer-based tasks to make sure the language and motor demands (e.g. using the mouse and keyboard) were appropriate.

 

Mrs S, a 70 years old lady who had a right middle cerebral artery stroke 4 months ago, is living at home with her husband and is presenting with left sided hemiparesis and mild to moderate cognitive/EF problems. She is independent for basic self-care activities (e.g. dressing, grooming) but she has difficulty planning and organizing things and perceiving errors while performing more complex instrumental activities of daily living tasks (e.g. preparing a meal). Also, it is difficult for her to deal with unexpected situations and she sometimes gets anxious in unfamiliar environments (e.g. when visiting friends, going to the shopping center, etc…). She is currently receiving a problem-solving training intervention, which consists of learning and applying strategies to solve her everyday problems.

Clinician management: To facilitate transfer and generalization of strategy use at home, several training sessions are conducted in her home and community environment with her spouse present. 

Who offers these treatments?

Occupational therapists (OT), neuropsychologists and speech language pathologists can provide intervention for EF problems at an acute care hospital, rehabilitation centre, or private clinic.

References

Alderman, N., Burgess, P. W., Knight, C. & Henman, C. (2003). Ecological validity of a simplified version of the multiple errands shopping test. Journal of the International Neuropsychological Society, 9(1), 31-44.

Anderson, P. J. (2008). Towards a developmental model of executive function.In: V. Anderson, R. Jacobs & P. Anderson(Eds.),Executive functions and the frontal lobes: A lifespan perspective (pp. 3-21). New York, NY: Taylor & Francis.

Baguena, N., Thomas-Anterion, C., Sciessere, K., Truche, A., Extier, C., Guyot, E. et al. (2006). Ecologic evaluation in the cognitive assessment of brain injury patients: generation and execution of script.[French] Apport de l’évaluation de la cognition dans une tâche de vie quotidienne chez des patients cérébrolésés : génération et exécution d’un script de cuisine. Annales de Réadaptation et de Médecine Physique, 49(5), 234-241.

Barnes, A. & Thagard, P. (1996). Emotional decisions. In: G. W. Cottrell (Ed.),Proceedings of the Eighteenth Annual Conference of the Cognitive Science Society, (pp. 426–429). Mahwah, NJ: Lawrence Erlbaum Associates.

Baum, C. M., Connor, L. T., Morrison, T., Hahn, M., Dromerick, A. W. & Edwards, D. F. (2008). Reliability, validity, and clinical utility of the Executive Function Performance Test: A measure of executive function in a sample of people with stroke. American Journal of Occupational Therapy, 62(4), 446-455.

Baum, C. M., Morrison, T., Hahn, M. & Edwards, D. F. (2007). Test Protocol Booklet: Executive Function Performance Test. St. Louis, MO: Washington University School of Medicine.

Chevignard, M., Pillon, B., Pradat-Diehl, P., Taillefer, C., Rousseau, S., Le Bras, C. et al.(2000). An ecological approach to planning dysfunction: Script execution. Cortex, 36, 649-669.

Chevignard, M. P., Taillefer, C., Picq, C., Poncet, F., Noulhaine, M. & Pradat-Diehl, P. (2008). Ecological assessment of the dysexecutive syndrome using execution of a cooking task. Neuropsychological Rehabilitation, 18(4), 461-485.

Cicerone, K. D., Dahlberg, C., Kalmar, K., et al. (2000). Evidence-based cognitive rehabilitation: recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation, 81, 1596-1615.

Dawson, D. R., Anderson, N. D., Burgess, P., Cooper, E., Krpan, K. M. & Stuss, D. T. (2009). Further development of the Multiple Errands Test: standardized scoring, reliability, and ecological validity for the Baycrest version. Archives of Physical Medicine & Rehabilitation, 90(11 Suppl), S41-51.

D’Elia, L. F., Satz, P., Uchiyama, C.L., & White, T. (1996). Color Trails Test. Odessa, FL: PAR.

Diehl, M., Marsiske, M., Horgas, A. L., Rosenberg, A., Saczynski, J. S. & Willis, S. L. (2005). The Revised Observed Tasks of Daily Living: A Performance-Based Assessment of Everyday Problem Solving in Older Adults. The Journal of Applied Gerontology, 24(3), 211-230.

Dubois, B., Slachevsky, A., Litvan, I., & Pillon, B. (2000).The FAB: A frontal assessment battery at bedside. Neurology, 55(11), 1621-1626.

Dutil, E., Bottari, C., Vanier, M. & Gaudreault, C. (2005). ADL Profile: Description of the instrument, 4th ed. Montreal: Les Éditions Émersion.

Evans, J. J. (2009). Rehabilitation of executive functioning: an overview. In: Oddy M, Worthington A, eds. The rehabilitation of executive disorders: a guide to theory and practice. New York: Oxford University Press, 59-73.

Evans, J. J., Emslie, H., Wilson, B. A. (1998). External cueing systems in the rehabilitation of executive impairments of action. J Int Neuropsychol Soc, 4, 399-408.

Fish J, Manly T, Emslie H, Evans JJ, Wilson BA. Compensatory strategies for acquired disorders of memory and planning: differential effects of a paging system for patients with brain injury of traumatic versus cerebrovascular aetiology. J Neurol Neurosurg Psychiatry 2008(8):930-935.

Fish, J., Manly, T., Wilson, B. A. (2008). Long-term compensatory treatment of organizational deficits in a patient with bilateral frontal lobe damage. J Int Neuropsychol Soc, 14, 154-163.

Fisher, A. G. & Bray Jones, K. (2010a). Assessment of Motor and Process Skills. Vol. 1: Development, Standardization, and Administration Manual, 7th ed. Fort Collins, CO: Three Star Press.

Fisher, A. G. & Bray Jones, K. (2010b). Assessment of Motor and Process Skills. Vol. 2: User Manual, 7th ed. Fort Collins, CO: Three Star Press.

Godefroy, O. & Stuss, D. T. (2007). Dysexecutive syndromes. In: O. Godefroy & J. Bogousslavsky (Eds.),The behavioral and cognitive neurology of stroke (pp. 369-406). Cambridge: Cambridge University Press.

Grieve, J. L. & Gnanasekaran, L. (2008). Neuropsychology for occupational therapists: cognition in occupational performance, 3rd ed. Oxford, UK: Blackwell Publishing.

Hartman-Maeir, A., Harel, H. & Katz, N. (2009). Kettle Test – A brief measure of cognitive functional performance: Reliability and validity in a stroke population. American Journal of Occupational Therapy, 64, 592-599.

Henshaw, E., Polatajko, H., McEwen, S., Ryan, J. D., Baum, C. M. (2011). Cognitive approach to improving participation after stroke: two case studies. Am J Occup Ther, 65(1), 55-63.

Honda, T. (1999). Rehabilitation of executive function impairments after stroke. Top Stroke Rehabil, 1, 15-22.

Klinger, E., Chemin, I., Lebreton, S. & Marié, R.M. (2004). A virtual supermarket to assess cognitive planning. Cyberpsychology & Behavior, 7, 292–293.

Klinger, E., Chemin, I., Lebreton, S. & Marié, R.M. (2006). Virtual Action Planning in Parkinson’s Disease: a control study. Cyberpsychology & Behavior,9, 342-347.

Knight, C., Alderman, N. & Burgess, P. W. (2002). Development of a simplified version of the multiple errands test for use in hospital settings. Neuropsychological Rehabilitation, 12(3), 231-256.

Lamberts, K. F., Evans, J. J. & Spikman, J. M. (2010). A real-life, ecologically valid test of executive functioning: The executive secretarial task. Journal of Clinical and Experimental Neuropsychology, 32(1), 56-65.

Larson, E. B., & Heinemann, A. W. (2010). Rasch analysis of the Executive Interview (The EXIT-25) and introduction of an abridged version (The Quick EXIT). Archives of Physical Medicine & Rehabilitation, 91(3), 389-394.

Lesniak, M., Bak, T., Czepiel, W., Seniow, J. & Czlonkowska, A. (2008). Frequency and prognostic value of cognitive disorders in stroke patients. Dementia and Geriatric Cognitive Disorders, 26, 356-363.

Levine, B., Schweizer, T. A., O’Connor, C., Turner, G., Gillingham, S., Stuss, D. T., Manly, T. & Robertson, I. H. (2011). Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training. Front. Hum. Neurosci. 5:9. doi: 10.3389/fnhum.2011.00009

Levine, B., Turner, G. R., Stuss, D. T. (2008).Rehabilitation of frontal lobe functions. In: Stuss DT, Winocur G, Robertson IH, eds. Cognitive Neurorehabilitation: Evidence and Application (2nd ed.). United Kingdom: Cambridge University Press, 464-486.

Lezak, M. (1989). Assessment of Psychosocial Dysfunctions Resulting from Head Trauma. In: M. Lezak (Ed.),Assessment of the Behavioral Consequences of Head Trauma. New York: Alan Liss Inc.

Lindsay, M.P., Gubitz, G., Bayley, M., et al. (2010). Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the Canadian Stroke Strategy Best Practices & Standards Writing Group 2010: Ottawa, Ontario, Canada: Canadian Stroke Network.

Lundqvist, A., Grundström, K., Samuelsson, K., önnberg, J. (2010). Computerized training of working memory in a group of patients suffering from acquired brain injury. Brain Injury, 24(10), 1173-83. doi: 10.3109/02699052.2010.498007.

Luria, A. R. (1966). Higher cortical functions in man. New York: Basic Books.

Macdonald, S. & Johnson, C. (2005). Assessment of subtle cognitive-communication deficits following acquired brain injury: A normative study of the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES). Brain Injury, 19(11), 895-902.

Maj, M., D’Elia, L. D., Satz, P., Janssen, R., Zaudig, M., Uchiyama, C., Starace, F., Galderisi, S., & Chervinsky, A. (1993). Evaluation of two new neuropsychological tests designed to minimize cultural bias in the assessment of HIV-1 Seropositive persons: a WHO study. Archives of Clinical Neuropsychology, 8, 123-35.

Man, D. W., Soong, W. Y., Tam, S. F., Hui-Chan, C. W. (2006). A randomized clinical trial study on the effectiveness of a tele-analogy-based problem-solving programme for people with acquired brain injury (ABI). NeuroRehabilitation, 21, 205-217.

Manly, T., Hawkins, K., Evans, J., Woldt, K., & Robertson, I. H. (2002). Rehabilitation of executive function: facilitation of effective goal management on complex tasks using periodic auditory alerts. Neuropsychologia, 40(3), 271-81.

McDowd, J.M., Filion, D.L., Pohl, P.S., Richards, L.G., Stiers, W. (2003). Attentional abilities and functional outcomes following stroke. J Gerontol B Psychol Sci Soc Sci, 58, P45-53.

McEwen, S. E., Polatajko, H. J., Davis, J. A., Huijbregts, M., & Ryan, J. D. (2010a). ‘There’s a real plan here, and I am responsible for that plan’: participant experiences with a novel cognitive-based treatment approach for adults living with chronic stroke. Disabil Rehabil, 32(7), 540-550.

McEwen, S. E., Polatajko, H. J., Huijbregts, M. P., & Ryan, J. D. (2009). Exploring a cognitive-based treatment approach to improve motor-based skill performance in chronic stroke: Results of three single case experiments. Brain Inj, 23(13-14), 1041-1053.

McEwen, S. E., Polatajko, H. J., Huijbregts, M. P., & Ryan, J. D. (2010b). Inter-task transfer of meaningful, functional skills following a cognitive-based treatment: Results of three multiple baseline design experiments in adults with chronic stroke. Neuropsychol Rehabil, 20(4), 541-561.

Nasreddine, Z. S., Phillips, N. A., Bediriam, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53, 4, 695-699.

Neistadt, M. E. (1992). The Rabideau kitchen evaluation – revised: An assessment of meal preparation skill. Occupational Therapy Journal of Research, 12, 242-253.

Neistadt, M. E. (1994). A meal preparation treatment protocol for adults with brain injury. American Journal of Occupational Therapy, 48, 431–438.

Oddy, M., & Herbert, C. (2009). The family and executive disorders. In M. Oddy & A. Worthington (Eds.),The rehabilitation of executive disorders: a guide to theory and practice (pp. 327-339). New York: Oxford University Press.

Ownsworth, T., Shum, D. (2008). Relationship between executive functions and productivity outcomes following stroke. Disabil Rehabil, 30, 531-540.

Polatajko, H. J., & Mandich, A. (2004). Enabling Occupation in Children: The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach.Ottawa, Ontario: CAOT Publications.

Polatajko, H. J., McEwen, S. E., Ryan, J. D., Baum, C. M. (2012). Pilot randomized controlled trial investigating cognitive strategy use to improve goal performance after stroke.Am J Occup Ther, 66(1), 104-9.

Ponsford, J. (2008). Rehabilitation of attention following traumatic brain injury. In D. T. Stuss, G. Winocur, & I. H. Robertson (Eds.),Cognitive Neurorehabilitation: Evidence and Application (2nd ed.) (pp. 507-521). United Kingdom: Cambridge University Press.

Poulin, V., Korner-Bitensky, N. & Dawson, D. (2013). Stroke-specific executive function assessment: A literature review of performance-based tools. Australian Occupational Therapy Journal, 60(1), 3-19. doi: 10.1111/1440-1630.12024.

Poulin, V., Korner-Bitensky, N., Dawson, D., & Bherer, L. (2012). Efficacy of executive function interventions after stroke: a systematic review. Topics in Stroke Rehabilitation, 19(2), 158-171.

Rand, D., Weiss, P. L. & Katz, N. (2009). Training multitasking in a virtual supermarket: a novel intervention after stroke. American Journal of Occupational Therapy, 63(5), 535-542.

Rath, J. F., Langenbahn, D. M., Simon, D., Sherr, R. L., Fletcher, J. & Diller, L. (2004). The construct of problem solving in higher level neuropsychological assessment and rehabilitation. Archives of Clinical Neuropsychology, 19, 613-635.

Reitan, R. M. (1986). Trail Making Test manual for administration and scoring. Tucson (AZ): Reitan Neuropsychology Laboratory.

Riepe, M. W., Riss, S., Bittner, D. & Huber, R. (2004). Screening for cognitive impairment in patients with acute stroke. Dementia and Geriatric Cognitive Disorders, 17, 49-53.

Royall, D. R., Mahurin, R. K., & Gray, K. F. (1992). Bedside assessment of executive cognitive impairment: the executive interview. Journal of the American Geriatrics Society, 40(12), 1221-1226.

Royall, D. R., Palmer, R., Chiodo, L. K., & Polk, M. J. (2004). Declining executive control in normal aging predicts change in functional status: the Freedom House Study. Journal of the American Geriatrics Society, 52(3), 346-352.

Schwartz, M. F., Segal, M., Veramonti, T., Ferraro, M. & Buxbaum, L. J. (2002). The Naturalistic Action Test: A standardised assessment for everyday action impairment,Neuropsychological Rehabilitation, 12(4), 311-339.

Schweizer, T. A., Levine, B., Rewilak, D., et al.(2008). Rehabilitation of executive functioning after focal damage to the cerebellum. Neurorehabil Neural Repair, 22, 72-77.

Shallice, T. & Burgess, P. W. (2001). Deficits in strategy application following frontal lobe damage in man. Brain, 114, 727-741.

Skidmore, E. R., Holm, M. B., Whyte, E. M., Dew, M. A., Dawson, D., Becker, J. T. (2011). The feasibility of meta-cognitive strategy training in acute inpatient stroke rehabilitation: case report. Neuropsychol Rehabil, 21(2), 208-23. doi: 10.1080/09602011.2011.552559.

Skidmore, E.R., Whyte, E.M., Holm, M.B., et al. (2010). Cognitive and affective predictors of rehabilitation participation after stroke. Arch Phys Med Rehabil, 91, 203-207.

Stablum, F., Umilta, C., Mogentale, C., Carlan, M., Guerrini, C. (2000).Rehabilitation of executive deficits in closed head injury and anterior communicating artery aneurysm patients. Psychol Res, 63, 265-278.

Stuss, D. T. (2009). Rehabilitation of frontal lobe dysfunction: a working framework. In M. Oddy & A. Worthington (Eds.),The rehabilitation of executive disorders: a guide to theory and practice (pp. 3-17). New York: Oxford University Press.

Stuss, D. T., Alexander, M. P., Floren, D., Binns, M. A., Levine, B., McIntosh, A. R., et al. (2002). Fractionation and localization of distinct frontal lobe processes: Evidence from focal lesions in humans. In D. T. Stuss & R. T. Knight (Eds.),Principles of frontal lobe function. New York: Oxford University Press.

Vallat, C., Azouvi, P., Hardisson, H., Meffert, R., Tessier, C., Pradat-Diehl, P. (2005).Rehabilitation of verbal working memory after left hemisphere stroke. Brain Inj, 19, 1157-1164.

Van der Linden, M., Poncelet, M. & Majerus, S. (2007).Working memory dysfunctions in stroke patients. In: O. Godefroy & J. Bogousslavsky (Eds),The Behavioral and Cognitive Neurology of Stroke, (pp. 431-443). Cambridge, UK: Cambridge University Press.

Westerberg, H., Jacobaeus, H., Hirvikoski, T., et al.(2007). Computerized working memory training after stroke — A pilot study. Brain Inj, 21, 21-29.

Wilson, B. A., Alderman, N., Burgess, P., Emslie, H. & Evans, J. J. (1996). Behavioral Assessment of the Dysexecutive Syndrome. Bury St. Edmunds, England: Thames Valley Test Company.

Wilson, B. A., Evans, J. J., Emslie, H., Alderman, N. & Burgess, P. (1998). The development of an ecologically valid test for assessing patients with dysexecutive syndrome. Neuropsychological Rehabilitation, 8(3), 213-228.

Wolf, T. J., Morrison, T. & Matheson, L. (2008). Initial development of a work-related assessment of dysexecutive syndrome: the Complex Task Performance Assessment. Work, 31(2), 221-228.

Zinn, S., Bosworth, H. B., Hoenig, H. M. & Swartzwelder, H. S. (2007).Executive function deficits in acute stroke. Archives of Physical Medicine and Rehabilitation, 88, 173-180.

Zoltan, B. (2007). Vision, perception, and cognition: a manual for the evaluation and treatment of the neurologically impaired adult(4th ed.). Thorofare, NJ: SLACK Incorporated

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References

Akerlund, E., Esbjörnsson, E., Sunnerhagen, K.S., Björkdahl, A. (2013). Can computerized working memory training improve impaired working memory, cognition and psychological health? Brain Injury, 27(13-4), 1649-57.
https://www.ncbi.nlm.nih.gov/pubmed/24087909

Faria, A. L., Andrade, A., Soares, L., & i Badia, S. B. (2016). Benefits of virtual reality based cognitive rehabilitation through simulated activities of daily living: a randomized controlled trial with stroke patients. Journal of NeuroEngineering and Rehabilitation, 13(1), 96.
https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0204-z

Fish J, Manly T, Emslie H, Evans J & Wilson B. (2008). Compensatory strategies for acquired disorders of memory and planning: differential effects of a paging system for patients with brain injury of traumatic versus cerebrovascular etiology. J Neurol Neurosurg Psychiatry, 79, 930-935.
http://www.ncbi.nlm.nih.gov/pubmed/18039889

Gamito, P., Oliveira, J., Coelho, C., Morais, D., Lopes, P., Pacheco, J., & Barata, A. F. (2015). Cognitive training on stroke patients via virtual reality-based serious games. Disability and rehabilitation, 1-4.
http://www.tandfonline.com/doi/abs/10.3109/09638288.2014.934925

Lin, Z.C., Tao, J., Gao, Y.L., Yin, D.Z., Chen, A.Z., Chen, L.D. (2014). Analysis of central mechanism of cognitive training on cognitive impairment after stroke: resting-state functional magnetic resonance imaging study. Journal of International Medical Research, 42 (3), 659-68.
https://www.ncbi.nlm.nih.gov/pubmed/24722262

Lundqvist, A., Grundström, K., Samuelsson, K., Rönnberg, J. (2010). Computerized training of working memory in a group of patients suffering from acquired brain injury. Brain Injury, 24(10), 1173-83.
https://www.ncbi.nlm.nih.gov/pubmed/20715888

Man, D.W.K., Soong, W.Y.L., Tam, S.F., & Hui-Chan, C.W.Y. (2006). A randomized clinical trial study on the effectiveness of a tele-analogy-based problem-solving programme for people with acquired brain injury (ABI). NeuroRehabilitation, 21, 205-17.
https://www.ncbi.nlm.nih.gov/pubmed/17167189

Poulin, V., Korner-Bitensky, N., Bherer, L., Lussier, M., & Dawson, D.R. (2016). Comparison of two cognitive interventions for adults experiencing executive dysfunction post-stroke: a pilot study. Disability and Rehabilitation, ISSN: 0963-8288.
https://www.ncbi.nlm.nih.gov/pubmed/26750772

Prokopenko, S.V., Mozheyko, E.Y., Petrova, M.M., Koryagina, T.D., Kaskaeva, D.S., Chernykh, T.V., et al. (2013). Correction of post-stroke cognitive impairments using computer programs. Journal of the Neurological Sciences, 325 (1), 148-53.
http://www.ncbi.nlm.nih.gov/pubmed/23312291

Skidmore, E.R., Dawson, D.R., Butters, M.A., Grattan, E.S., Juengst, S.B., Whyte, E.M., Begley, A., Holm, M.B., & Becker, J.T. (2015a). Strategy training shows promise for addressing disability in the first 6 months after stroke. Neurorehabilitation and Neural repair, 29(7), 668-76.
https://www.ncbi.nlm.nih.gov/pubmed/25505221

Skidmore, E.R., Whyte, E.M., Butters, M.A., Terhorst, L., & Reynolds III, C.F. (2015b). Strategy training during inpatient rehabilitation may prevent apathy symptoms after acute stroke. Physical Medicine and Rehabilitation, 7, 562-70.
https://www.ncbi.nlm.nih.gov/pubmed/25595665

Westerberg, H., Jacobaeus, H., Hirvikoski, T., Clevberger, P., Östensson, M.L., Bartfai, A., et al. (2007). Computerized working memory training after stroke – a pilot study. Brain Injury, 21(1), 21-9.
https://www.ncbi.nlm.nih.gov/pubmed/17364516

Winkens, I., Van Heugten, C.M., Wade, D.T., Habets, E.J., & Faostti, L. (2009). Efficacy of time pressure management in stroke patients with slowed information processing: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90, 1672-9.
http://www.ncbi.nlm.nih.gov/pubmed/19801055

Wolf, T.J., Polatajko, H., Baum, C., Rios, J., Cirone, D., Doherty, M., & McEwen, S. (2016). Combined cognitive-strategy and task-specific training affects cognition and upper-extremity function in subacute stroke: an exploratory randomized controlled trial. The American Journal of Occupational Therapy, 70(2), 1-10.
http://www.ncbi.nlm.nih.gov/pubmed/26943113

Zucchella, C., Capone, A., Codella, V., Vecchione, C., Buccino, G., Sandrini, G., et al. (2014). Assessing and restoring cognitive functions early after stroke. Functional Neurology, 29(4), 255.
https://www.ncbi.nlm.nih.gov/pubmed/25764255

Excluded References and Reasons for Exclusion:

Hildebrandt, H., Bussmann-Mork, B., & Schwendemann, G. (2006). Group therapy for memory impaired patients: a partial remediation is possible. Journal of Neurology253(4), 512-519.
Reason for exclusion: all groups received a form of memory training with varying intensities/strategies.

Jorge, R.E., Acion, L., Moser, D., Adams, Jr H.P., Robinson, R.G. (2010). Escitalopram and enhancement of cognitive recovery following stroke. Archives of General Psychiatry, 67(2), 187-96.
Reason for exclusion: main intervention is a medicament.

Lannin, N.A., Schmidt, J., Carr, B., Allaous, J., Falcon, A., & Tate, R. (2014). Occupational therapy training to use handheld personal digital assistant (PDA) devices to address memory and planning difficulties after acquired brain injury: a randomised controlled trial. Stroke, 45(12), 296.
Reason for exclusion: 5/42 patients are with stroke (i.e. <50%).

Poulin, V., Korner-Bitensky, N., Dawson, D.R., & Bherer, L. (2012). Efficacy of executive function interventions after stroke: a systematic review. Topics in Stroke Rehabilitation, 19(2), 158-71. Reason for exclusion: review.

Rozental-Iluz, C., Zeiling, G., Weingarden, H., & Rand, D. (2016). Improving executive function deficits by playing interactive video-games: secondary analysis of a randomized controlled trial for individuals with chronic stroke. European Journal of Physical and Rehabilitation Medicine, 52(4), 508-15. Reason for exclusion: nature of the intervention.

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